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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005960
Report Date: 06/01/2021
Date Signed: 06/28/2021 10:04:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WOODBRIDGE TERRACEFACILITY NUMBER:
306005960
ADMINISTRATOR:PRATT, STEPHENFACILITY TYPE:
740
ADDRESS:1 WITHERSPOONTELEPHONE:
(760) 804-5900
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:180CENSUS: 80DATE:
06/01/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Stephen Pratt, Executive DirectorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst, Kathrina Chin made an announced site visit for the purpose of a pre-licensing evaluation. LPA Chin met and spoke with Stephen Pratt, Executive Director. This application is a change of ownership.

The main structure is a three story building which includes 142 resident units in total. The entire community was designed to accommodate 180 residents. There is a Memory Care unit on the first floor and has a capacity for 25 residents. There are five delayed egress exits on the first floor. A fire clearance was granted on March 31, 2021 for 140 non-ambulatory and 40 ambulatory residents. This facility has submitted a hospice waiver request for 14 residents.

LPA toured the entire community, interior and exterior, including a sampling of resident bedroom units. Hot water were tested in 6 apartment units and observed to be between 114.3-121.2 degrees Fahrenheit. The hot water temperature was lowered to 116 degrees Fahrenheit in the boiler by the Maintenance Director. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors are operational. There was one E-Vacs chairs near each of the five stairwells at the facility. The two medications There were first aids in each of the two medication rooms on the first floor. There are first aid kits are also stored in the kitchen and the front desk area. There were several locked closets for storage of toxins and cleaning equipment. The facility utilizes emergency pendents for emergency response from staff and care related purposes. The kitchen area was checked. There were emergency food supplies and water. LPA observed activity calendars, theft and loss policy, residents rights, admission agreement, and emergency plans were posted including the Ombudsman and Let Us Know poster. The Memory Care unit has their own activity room/ living room area and dining area. LPA reviewed the outdoor area and observed patio chairs and umbrellas for shade. (Continued on LIC 809)
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WOODBRIDGE TERRACE
FACILITY NUMBER: 306005960
VISIT DATE: 06/01/2021
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(Continued)

An Abbreviated Component III was conducted with Stephen Pratt, Executive Director.

It appears that this facility meets the requirements for licensure. Both the license and the hospice waiver will be granted upon final review and approval from the Central Applications Bureau.
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An exit interview was conducted with Stephen Pratt, ED and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
LIC809 (FAS) - (06/04)
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